An unethical, imprecise, potentially illegal x-ray practice

A few months ago, a section of the media reported that as many as 102 children, including orphans, received certificates of age after a dental college in Navi Mumbai used a dental x-ray method to determine their age. For this, the College signed an MoU with Date of Birth Foundation (DoBF), a Hong Kong -based and Chennai- registered NGO.

“In the first phase of the project, 100 children without birth documents were identified from Navi Mumbai region and brought to the dental college, where dental x-rays were obtained and age estimation was done. Hence, age certificates will be issued to these children; now, these kids have a date to remember and celebrate in their lives,” The Daily News and Analysis (The DNA, August 14) quoted the Dean of the college.

“Illegitimate children, children in orphanages, children born at home do not have birth certificates. Through this procedure, we will be able to give them age certificates”, he revealed to The DNA.

Shortly afterwards, the Atomic Energy Regulatory Board issued a press release asserting that it does not approve of such routine use of dental x- ray examination of any person solely for age determination as a justified practice. AERB advised all the medical/dental x-ray facilities, dentists/dental surgeons as well as the general public to desist from using dental x-ray examination solely for the purpose of age determination or birth registration. AERB highlighted the fact that x-ray examinations are to be carried out only when it is considered as a medical necessity.

X-ray is a double-edged sword. Children are vulnerable; they are more radiosensitive than adults. Dental x rays expose radiosensitive tissues such as, bone marrow in the head, thyroid, brain and eye lens. Radiation doses to children undergoing the test are very low; however, in an unjustified procedure, any dose is high dose and is unacceptable. Children need not take the small risk as the test offers no direct health benefit. There are legally acceptable procedures without x-ray tests to issue birth certificates to unregistered children.

In a 26 page review in The British Medical Bulletin (May 14, 2012) , specialists from University College London, Medical Research Council’s Centre of Epidemiology for Child Health, among others asserted that imaging of bones or teeth can never indicate precisely the chronological age of the individual. They argued that these tests are imprecise, unethical and potentially unlawful.

When comparative normative images exist “at best, chronological age correlates to +2 years or -2 years of maturity age”…. “In some entirely normal children, this may be discordant by as much as 4–5 years,” they clarified. Writing in Annals of Human Biology (2 July 2015), one of the authors, Prof T J Cole, UCL Institute of Child Health, London concluded that “the use of developmental markers, be they skeletal, dental or other, for age assessment purposes, is imperfect and where they are used, the quality of their evidence should be challenged.”

“I don’t claim any expertise for age ranges other than majority at 18 years. But my conclusions will certainly apply at other ages,” he responded to my email query.

Is the method sensitive enough to decide the ‘Date’ of Birth?

“Of course we don’t claim to estimate the exact date of birth. What happens is that the administrators accept the Dental Age Estimate (DAE) and then for the purposes of administration, convert the DAE to an exact Date of birth,” Dr. G J Roberts, King’s College London Dental Institute, who developed the method responded to an e-mail query.

In a later message, he stated that they are in the midst of writing up a series of papers that will provide the most up to date and comprehensive reports on the applicability of Dental Age Estimation.

“These need to go through the independent reviewing process so it would be premature of me to release the data before this is complete,” he clarified. Obviously, the procedure is just a work in progress!

The agencies not supporting age determination by dental x-ray method include the British Medical and Dental Associations, the General Medical and Dental councils, The Royal Colleges of Paediatrics and Child Health and Radiology, senior officials in the UK Department of Health; the British Society for Paediatric Endocrinology and Diabetes, the Council of the European Society for Paediatric Endocrinology, The International Olympic Committee and Federation Internationale de Football Association (FIFA), UNICEF, Royal Australasian College of Physicians and Radiologists and Australasian Paediatric Endocrine Group.